Applicant makes case that treatment plans are reasonable and necessary - Applicant v Echelon LAT 16-003223

July 19, 2017, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

Applicant v Echelon LAT 16-003223

Date of Decision: June 20, 2017
Heard Before: Arbitrator S. F. Mather

Entitlement to treatment: Applicant makes case that treatment plans are reasonable and necessary.

The applicant was in a car accident on March 14, 2010 when the car he was operating was rear-ended. The applicant and his wife were both injured in the accident and their two-year-old daughter sustained fatal injuries.  In April 2014, the applicant was found to be catastrophically impaired as a result of the accident. In June 2014, the applicant sought a rehabilitation benefit pursuant to the SABS.  At the time of the application the applicant was 34 years old with two young children at home.

The applicant was seeking to continue the services of Lisa Hutchinson an occupational therapist to help him improve his level of function in his activities of daily living and interaction with his children. Echelon denied the benefit on the basis that the Treatment and Assessment Plan in dispute (“treatment plan”) provided no clear rational as to why occupational therapy treatment continued to be required and did not specify any measurable treatment goals, achievable time lines and/or implementation strategies for the applicant to achieve his functional goals. The applicant disagreed with this decision and submitted an application to the LAT.

Issues:

1. Is the applicant entitled to receive a rehabilitation benefit in the amount of $2,388.93 for an in-home assessment, occupational therapy treatments, meetings and administrative expenses recommended in a treatment plan dated June 30, 2014, denied by Echelon on October15, 2014?
2. Is the applicant entitled to interest on any overdue payment of benefits?
3. Is the applicant entitled to costs?

RESULT

1. The applicant is entitled to receive a rehabilitation benefit in the amount of $2,388.93 for an in-home assessment, occupational therapy treatments, meetings and administrative expenses recommended in a treatment plan dated June 30, 2014 and denied by Echelon on October 15, 2014?
2. The applicant is entitled to interest on the overdue payment of benefits.
3. The applicant is not entitled to costs.

The Arbitrator reviewed the law and the evidence in the case. He noted that Section 15(1) of the Schedule requires an insurer to a pay rehabilitation benefit to an insured person who sustains impairment as a result of an accident, and for all reasonable and necessary measures undertaken by an insured person to reduce or eliminate the effects of any disability resulting from the impairment or to facilitate the insured person’s reintegration into his or her family, the rest of society and the labour market.  The burden of proof rests with the applicant to show on the balance of probabilities that the rehabilitation benefits sought are reasonable and necessary.

The Arbitrator reviewed the substantial medical evidence, a Functional Abilities Evaluation, and IE (psychiatry), and an OT report. An April 2014 psychiatry report determined that the applicant was catastrophically impaired. It found that the applicant has moderate impairment in the area of Activities of Daily Living, moderate impairment in social functioning and marked impairment in the domains of concentration, persistence, pace and adaptation.

Echelon denied the treatment plan on the basis of the “Independent Occupational Therapy In Home Assessment” report of occupational therapist, and other earlier examinations and assessments included in its document brief. The Arbitrator did not prefer the reports from Echelon, nor the reasons given for denying the plan, namely that the applicant has failed to meet the burden of proof to show that the treatment plan was reasonable and necessary.

The Arbitrator found that the goals identified in the treatment plan are goals that are reasonable and necessary to reduce the effects of the applicant’s disabilities arising from the accident. Based on the evidence there is no doubt that the applicant was not functioning well either physically or psychologically and needed assistance to reduce the effects of his disabilities from the accident. After reviewing the documentary evidence and written submissions of the parties the Arbitrator was  satisfied that the expenses contemplated by the treatment plan in dispute were for reasonable and necessary measures for the applicant’s rehabilitation.

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Deutschmann Law serves South-Western Ontario with offices in Kitchener-Waterloo, Cambridge, Woodstock, Brantford, Stratford and Ayr. The law practice of Robert Deutschmann focuses almost exclusively in personal injury and disability insurance matters. For more information, please visit www.deutschmannlaw.com or call us at 1-519-742-7774.

It is important that you review your accident benefit file with one of our experienced personal injury / car accident lawyers to ensure that you obtain access to all your benefits which include, but are limited to, things like physiotherapy, income replacement benefits, vocational retraining and home modifications.